Advanced | Acute Pain and Anesthesia Flashcards by Hashim Abdullah

This is the current optimum duration of epidural analgesia as per recommendations by literature and barash:

A. 2 - 4 days

B. 5 days

C. 24 hours - 48 hours

D. less than 24 hours

A. 2 - 4 days

The optimal duration of epidural analgesia has not been determined, but recommendations are that the infusion be continued for at least 2 to 4 days.

Epidural infusions lasting less than 24 hours do not appear to offer any clear cardiovascular
advantages.

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As a 2 year resident rotating at the pain clinic, you were asked which of the following opioid is considered the EPIDURAL OPIOID of choice for an opioid-tolerant patient taking more than 250mg/d of oral morphine?

A. Hyrdomorphone
B. Remifentanil
C. Sufentanil
D. Tramadol

C. Sufentanil

Sufentanil may be considered the epidural opioid of choice in the opioid-tolerant
patient taking more than 250 mg/d of oral morphine because of its
high intrinsic activity.

Opioids with intermediate lipophilicity (e.g., hydromorphone, alfentanil, and meperidine) can easily move between the aqueous and lipid regions of the arachnoid membrane and therefore have high meningeal permeability.

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TRUE of FALSE

A systemic opioid should not be used in combination with a neuraxial opioid like epidural morphine.

TRUE

It is not recommended to
administer opioids by multiple simultaneous routes because of the potential for additive respiratory depressant effects.

A systemic opioid (e.g., PCA) should not be used in combination with a neuraxial opioid (e.g., epidural morphine).

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One of the clinical advantage of clonidine as intrathecal agent is:

A. Intrathecal clonidine does not cause respiratory depression or pruritus

B. Intrathecal clonidine does not cause respiratory depression but causes pruritus

C. Intrathecal clonidine both causes respiratory depression and pruritus

D. Intrathecal clonidine does
not cause respiratory depression but causes pruritus and PONV

A. Intrathecal clonidine does not cause respiratory depression or pruritus

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A patient is said to OPIOID-TOLERANT if his/her use of oral morphine is:

A. more than or equal to 60mg/day for 1 week or longer

B. more than or equal to 90mg/day for 1 week or longer

C. more than or equal to 60mg/day for 10 days or longer

D. more than or equal to 90mg/day for 10 days of longer

A. more than or equal to 60mg/day for 1 week or longer

The U.S. FDA defines opioid tolerance as the use of the oral morphine equivalent of greater than or equal to 60 mg a day for 7 days or longer.

Recent evidence suggests that the opioid-tolerant patient can potentially have
a complicated hospital course resulting in an increased hospital LOS and a
high readmission rate

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All of the following are considered effective FIRST-LINE agents in treating spine pain EXCEPT:

A. NSAID’s
B. Muscle relaxant
C. Physical therapy
D. Anti-epileptics
E. Acetaminophen

E. Acetaminophen

Physical therapy, NSAIDs, acetaminophen, and short courses of muscle relaxants are effective first-line agents in treating spine pain.

Antiepileptics are not effective in treating low back pain or lumbosacral radicular pain

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TRUE or FALSE

In general, traditional analgesic therapies have only targeted pain perception.

TRUE

In general, traditional analgesic therapies have only targeted pain perception.

A multimodal approach to pain therapy should target ALL FOUR ELEMENTS of the
pain-processing pathway.

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This is a specific example of central plasticity that results from repetitive C-fiber stimulation of WDR neurons in the dorsal horn:

A. ‘Wind up’

B. OIH

C. Tolerance

D. Allodynia

A. ‘Wind up’

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An exaggerated response to pain at
the site of injury:

A. Primary hyperalgesia

B. Tolerance

C. Allodynia

D. Spinal modulation

A. Primary hyperalgesia

Peripheral sensitization of
polymodal C fibers and high-threshold mechanoreceptors by these chemicals
leads to primary hyperalgesia, which is an exaggerated response to pain at
the site of injury.

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Which of the following compound is INHIBITORY?

A. Glycine

B. Substance P

C. Neurokinin A

D. Glutamate

A. Glycine

Three classes of transmitter compounds integral to pain transmission include

(1) the excitatory amino acids glutamate and aspartate

(2) the excitatory neuropeptides substance P and neurokinin A

(3) the inhibitory amino acids glycine and GABA

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Which of the following compound is EXCITATORY?

A. Glycine

B. GABA-A

C. Endorphin

D. GABA-2

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This allogenic substance is produced from PLATELET:

A. Serotonin

B. TNF

C. Interleukin

D. Bradykinin

A. Serotonin

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This allogenic substance is produced from MACROPHAGES:

A. Serotonin

B. Glutamate

C. Adenosine

D. Bradykinin

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Prolonged depolarizations of second-order neurons leads to:

A. Primary hyperalgesia

B. Tolerance

C. Allodynia

D. Spinal modulation

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This is an increased pain response evoked by stimuli OUTSIDE the area of injury:

A. Secondary hyperalgesia

B. Primary hyperalgesia

C. Allodynia

D. Spinal modulation

A. Secondary hyperalgesia

Repetitive C-fiber stimulation of WDR neurons in the dorsal horn at intervals of 0.5 to 1 Hz can precipitate the occurrence of windup and central sensitization.

This leads to secondary hyperalgesia, which, by definition, is an increased pain response evoked by stimuli outside the area
of injury.

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TRUE or FALSE

Postoperative pain and the surgical stress response are not the same.

TRUE

Although similar, postoperative pain and the surgical stress response are not the same. Surgical stress causes release of cytokines (e.g., interleukin-1, interleukin-6, and tumor necrosis factor-α) and precipitates adverse neuroendocrine and sympathoadrenal responses, resulting in detrimental physiologic responses, particularly in high-risk patient.

The increased secretion of catabolic hormones such as cortisol, glucagon, growth hormone, and catecholamines and the decreased secretion of anabolic hormones such as insulin and testosterone characterize the neuroendocrine response.

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Preventive analgesia includes any antinociceptive regimen delivered at
ANY TIME during the perioperative period that will attenuate pain-induced
sensitization.

TRUE

The GOAL of preventive analgesia is to block the development of sustained pain.

TRUE

The goal of preventive analgesia is to block the development of sustained pain.

Theoretically, this occurs by preventing NMDA receptor activation in the dorsal horn that is associated with wind-up, facilitation, central sensitization expansion of receptive fields, and long-term potentiation, all of which can lead to a chronic pain state.

Three critical principles for PREVENTIVE ANALGESIA to be successful:

(1) the depth of analgesia must be adequate enough to block all nociceptive input during surgery

(2) the analgesic technique must be
extensive enough to include the entire surgical field

(3) the duration of
analgesia must include both the surgical and postsurgical periods

Which surgical procedure has a relatively high risk for neuropathic pain:

A. Cesarean Section

B. Inguinal Hernia repair

C. ORIF of upper limb

D. Tonsillectomy and Adenoid surgery

B. Inguinal Hernia repair

Neuropathic pain is a result of accidental nerve injury secondary to cutting, traction, compression, or entrapment.

Clinical features may include continuous burning, paroxysmal shooting, or electric pain with associated allodynia, hyperalgesia, and dysesthesias.

There can be a delay in the onset of the pain, and it can follow a non-dermatomal distribution.

Surgical procedures that are a relatively high risk for neuropathic pain include limb amputations, breast surgery,
gallbladder surgery, thoracic surgery, and inguinal hernia repair.

Nociceptive pain BEST responds to:

A. NMDA receptor
antagonists

B. α2-agonists

C. α2–δ subunit calcium channel ligands

D. NSAIDS

D. Nsaids

Nociceptive pain responds best to opioids, nonsteroidal anti-inflammatory
drugs (NSAIDs), para-aminophenol agents, and regional anesthesia
techniques.

Neuropathic pain, on the other hand, may benefit from the addition of the nonopioid analgesic adjuvants such as the NMDA receptor antagonists, α2-agonists, and the α2–δ subunit calcium channel ligands

True of PROTEIN BINDING:

A. FREE and BOUND fraction of the drug readily cross cell membranes

B. Acidic drugs bind to A1-acid glycoprotein

C. Basic drugs bind to ALBUMIN

D. It is the FREE FRACTION that determines the concentration of bound drug on the receptor

FREE and UNBOUND - not bound is readily crossing the cell membranes

ACIDIC drugs - ALBUMIN

BASIC - alpha1-glycoprotein

Remember, Free fraction determines the concentration!

Pain that escalates above a persistent background pain:

A. Hyperalgesia

B. Breakthrough pain

C. Intermittent background pain

D. Allydonia

B. Breakthrough pain

Acute pain may be viewed as breakthrough, intermittent, or background
in nature.

Which of the following are correctly paired with respect to opioid receptors:

A. Morphine - Mu1 and Kappa partial-antagonist

B. Meperidine - ORL1 antagonist

C. Fentanyl - Kappa partial antagonist

D. Methadone - Mu1 antagonist

E. Buprenorphine - Mu agonist & Kappa antagonist

The main opioid receptors:

mu (μ),
delta (δ)
kappa (κ)
opioid receptor-like 1 (ORL1).

The opioid receptors are members of a G protein–coupled (guanosine triphosphate regulatory proteins) receptor family, which signals via a second messenger such as cyclic adenosine monophosphate or an ion
channel.

Which of the following opioid is considered 'BROAD-spectrum' opioid? A. Nalbuphine B. Methadone C. Remifentanil D. Oxycodone E. Morphine

B. Methadone The “broadspectrum” opioid, methadone, also has NMDA receptor antagonist properties and inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of neuropathic pain.

One of the unique property of this opioid is it inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of NEUROPATHIC PAIN: A. Gabapentinoids B. Hydromorphone C. Fentanyl D. Oxycodone E. Methadone

Methadone The “broadspectrum” opioid, methadone, also has NMDA receptor antagonist properties and inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of neuropathic pain.

True of the GI adverse effects of OPIOID: A. Tolerance rarely develops to the constipating effects of the opioids B. Diarrhea is a major concern among opioid-naive patient C. Spasm of the GI smooth muscle is non-existent and negligible D. Biliary colic is rare

A. Tolerance rarely develops to the constipating effects of the opioids Numerous different pharmacologic approaches have been developed to combat OIC, which includes prolonged-release formulations that contain naloxone, tapentadol, and the peripherally acting MOR antagonists methylnaltrexone and alvimopan. The benefit of the addition of naloxone to long-acting opioids such as oxycodone is the reduced risk of diversion, given that the opioid is immediately antagonized if the tablet is crushed and injected or snorted.

True or False Respiratory depression in opioid is usually preceded by sedation?

TRUE

A phenomenon whereby patients who are receiving opioids suddenly and paradoxically become more sensitive to pain despite continued treatment with opioids: A. OIH (opioid-induced hyperalgesia) B. Tolerance C. Dependence D. Allodynia

A. OIH (opioid-induced hyperalgesia) Evidence suggests that OIH is more likely to develop following high doses of phenanthrene opioids such as morphine. Changing the opioid to a phenyl piperidine derivative such as fentanyl may thwart OIH. There is also evidence that coadministration of an NMDA receptor antagonist can abolish opioid-induced tolerance and OIH.]

Which is NOT an immunomodulatory effects of OPIOID: A. Inhibition of cellular and humoral immune functions B. Depressed natural killer cell activity C. Inhibition of angiogenesis D. Inhibition of apoptosis

C. Inhibition of angiogenesis - FALSE statement because PROMOTION OF ANGIOGENESIS is one of the immuno-modulatory effect of OPIOID Opioid analgesics have profound immunomodulatory effects, which include inhibition of cellular and humoral immune functions, depressed natural killer cell activity, promotion of angiogenesis, and inhibition of apoptosis. Such effects can be beneficial or deleterious depending upon the clinical situation

A patient presents with low back pain, biceps femoris weakness, and urinary incontinence after continuous spinal anesthesia. Which among the following is associated in this case? A. Use of a large-bore spinal catheter B. Maldistribution of LA C. Addition of epinephrine D. Use of chlorhexidine solution

B. Maldistribution of LA KEYWORD concept: * complications of SPINAL ANESTHESIA

The cauda equina may be more susceptible to chemical injury more than the proximal roots for what reason: A. The percentage of nerve volume to dural sac volume is DECREASED B. The cauda equina is not covered by meninges C. The cauda equina is covered only by the PIA matter D. CSF movement is unidirectional at this level

C. The cauda equina is covered only by the PIA matter Key concept: The anatomical relevance of cauda equina The meninges and their role in neuraxial anesthesia Movement of CSF is not unidirectional The catch here is which one is a TRUE statement.

Which of the following statement is FALSE regarding acute pain assessment: A. Visual analogue scale is equally effective as numeric rating scale and verbal categorical rating scale (VRS). B. Faces pain scale is well validated C. Assessment of pain during mobilization is more effective for pain control than at rest D. Mechanical allodynia is assessed by von-frey filaments.

A. Visual analogue scale is equally effective as numeric rating scale and verbal categorical rating scale (VRS) - FALSE statement. Verbal rating scale is less useful. It should be used only as a coarse screening instrument. Four point VRS instrument underestimates intense pain as compared to VAS. (Breivik EK, Bjornsson GA, Skovland E. A comparison of pain rating scale by sampling from clinical trial data. Clin J Pain. 2000;16:22–8). Faces pain scale is validated for more than 3 years of age. The faces pain scale revised: toward a common metric in paediatric pain measurement. Von frey filaments are made up of nylon hairs, of the same length but will different diameters to provide different range of forces especially from 0.008 gms force up to 300 gms force.

Which of the following pain modulating neurotransmitter is INHIBITORY? A. Glutamate B. Aspartate C. Vasoactive intestinal polypeptide D. Cholecystokinin E. Enkephalins

E. Enkephalins The rest of the choices are EXCITATORY neurotransmitters.:) Tatlo lang INHIBITORY according kay Miller: Enkephalins Somatostatin Endorphins

In PCA (patient-controlled analgesia), the minimum time interval that must elapse between dose administrations is known as: A. Lockout Interval B. Half-life C. ED50 D. Intermittent Bolus Per Interval Time

A. Lockout Interval

This is clinically defined as a rightward shift of the dose–response curve and is “a state in which an increased dosage of a psychoactive substance is needed to produce a desired effect.” A. Tolerance B. Withdrawal C. Dependence D. Withdrawal Syndrome

A. Tolerance

This commonly occurs in patients who are receiving chronic opioids, and this puts them at an increased risk for adverse consequences, particularly respiratory depression. A. Differential tolerance B. Innate Tolerance C. Dependence D. Withdrawal Syndrome

A. Differential tolerance

While doing a preoperative evaluation, you elicited in the history that the patient is currently taking oral morphine amounting to >60mg/day. This patient can be labeled as: A. Opioid-naive B. Opioid-exposed C. Opioid-tolerant D. Opioid-addict

C. Opioid-tolerant The opioid-tolerant patient is defined as having received >60 mg/d oral morphine equivalent in the 7 days prior to surgery. Opioid-tolerant patients have a greater likelihood of a complicated hospital course, which may manifest through delayed wound healing, increased surgical reintervention, prolonged hospital stays, higher readmission rates, greater health care costs, and increased mortality.

An OPIOID-NAIVE patient is: A. a patient who did no received opioid in the past 4 weeks B. a patient who did no received opioid in the previous 90 days C. a patient who did no received opioid in the previous 30 days D. a patient who did no received opioid in the previous 3 months

B. a patient who did no received opioid in the previous 90 days The opioid-naive patient is defined as having received NO opioids in the previous 90 days.

An OPIOID-EXPOSED patient is: A. a patient who did no received opioid in the past 4 weeks B. A patient with a history of opioid equivalent to monthly fentanyl patch of >10mg/day C. A patient with a history of <60 mg/day oral morphine equivalent in the previous 30 days. D. A patient with a history of <60 mg/day oral morphine equivalent in the previous 90 days.

The opioid-exposed patient has a history of <60 mg/d oral morphine equivalent in the previous 90 days.

Naltrexone is used in both alcohol- and opioid-dependent patients who are highly motivated to remain abstinent. Perioperatively, holding the oral formulation for 3 days prior to surgery is employed and scheduling surgery for at least 4 weeks after the last dose is done. The clinical significance of this preoperative advice is due to: A. These patients can experience opioid receptor upregulation due to chronic opioid antagonism with naltrexone B. These patients can experience opioid receptor downregulation due to chronic opioid antagonism with naltrexone C. These patient will have an opioid plateau which will require higher dose of opioid agonists D. These patient will have an opioid plateau which will require lower dose of opioid agonists

A. These patients can experience opioid receptor upregulation due to chronic opioid antagonism with naltrexone

A patient taking Naltrexone will have to be on hold for how long prior to a surgery? A. 1 week B. 3 days C. 24 hours D. 6 hours

B. 3 days